correct answer
d posterior tracheopexy.
Tracheomalacia (TM) refers to a weakening of the trachea caused by reduction of the longitudinal elastic fibers in the membranous trachea and/or impaired integrity of the cartilaginous rings that makes the airway susceptible to collapse during during forced expiration or coughing. The trachea can also be compressed by adjacent mediastinal structures - specifically the aortic arch and innominate artery anteriorly and the esophagus posteriorly. TM occurs most commonly in association with esophageal atresia but can also be seen with a number of congenital syndromes, vascular and cardiac anomalies, prematurity and prolonged intubation. A diagnosis of TM is suspected classically in the infant after esophageal atresia on the basis of a barky cough, expiratory stridor or recurrent pneumonias from impaired secretion clearance. Complete airway obstruction causes dying spells and brief resolved unexplained events (BRUE). Diagnosis is made by a combination of bronchoscopy during spontaneous ventilation and often cross sectional imaging.
The classic approach to TM associated with esophageal atresia has been aortopexy which elevates the anterior wall of the trachea but does not address the posterior intrusion of the membranous trachea. A recent meta-analysis suggests that up to 20% of patients with TM are either not improved or are worsened by aortopexy. Shieh recently presented an experience with 98 patients who underwent posterior tracheopexy for symptomatic TM. Of these, 69% had a prior esophageal atresia repair, 35% had associated congenital heart disease and eight had undergone previous aortopexy. Patients with a history of EA undergo a right posterior thoracotomy, while those with cardiac disease undergo sternotomy. The esophagus and posterior trachea are mobilized and the esophagus is displaced laterally. Posterior tracheopexy is performed by suturing the membranous trachea to the anterior longitudinal spinal ligament using pledgeted suture. Key to the operation is the intraoperative bronchoscopic visualization of the tracheal lumen. Posterior tracheopexy can be combined with either aortopexy or anterior tracheopexy, based on the bronchoscopic contour of the trachea. At five month median follow-up, there was a statistically significant improvement in all symptoms and the rates of lung infection well as a significant improvement in bronchoscopic appearance.
